Determination of Employment Work Status for Purposes of State of California Employment Taxes and Personal Income Tax Withholding

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1 Determination of Employment Work Status for Purposes of State of California Employment Taxes and Personal Income Tax Withholding Purpose This form is to be used by businesses who would like to get a determination as to whether a worker is an employee for purposes of California Unemployment Insurance, Employment Training Tax, State Disability Insurance*, and Personal Income Tax withholding. Note If you require any assistance in the completion of this form, contact the nearest Employment Tax Office of the Employment Development Department (EDD) or call (888) Upon completion, return to: STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT FACD-Central Operations, MIC 94 P.O. Box Sacramento, CA The EDD may need to contact you if additional information is required. General Information This form should be completed carefully, and it should be completed for one individual who is representative of the class of workers whose status is in question. If a written determination is desired for any other class of workers, complete a separate DE A written determination for any worker will apply to other workers of the same class if facts are not different from those of the worker whose status was ruled upon. This form is designed to cover many work activities. Some of the questions may not apply to you. You must answer questions 1-39 or mark them UNKNOWN or DOES NOT APPLY. Answer questions only if applicable. If additional space is needed, please attach another sheet. PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY * Includes Paid Family Leave (PFL). NAME OF FIRM NAME OF OWNER ADDRESS OF FIRM (CITY) (STATE) (ZIP CODE) TELEPHONE NUMBER (INCLUDING AREA CODE) FIRM S FEDERAL IDENTIFICATION NUMBER FIRM S EDD EMPLOYER ACCOUNT NUMBER Check the type of firm for which the work relationship is in question: Individual Partnership Corporation Limited Liability Company (LLC) Limited Liability Partnership (LLP) Other (specify): If the firm is a corporation, is the worker an officer of the corporation? Yes No If the firm is an LLC or LLP, is the worker a member of the LLC or partner in the LLP? Yes No DE 1870 Rev. 12 (2-09) (INTERNET) Page 1 of 7 CU

2 1. Provide a brief description of the firm s business (e.g., drug store, farmer, and construction): 2. Has this issue been the subject of a prior or current EDD audit and/or a benefit claim investigation or hearing? If Yes, please explain and provide any applicable dates: 3. Has any other governmental agency ruled on the status of services performed by the worker or another person performing the same or similar services? If Yes, please attach a copy. 4. Total number of workers in this class (Attach names, addresses, telephone numbers, and social security numbers. If more than 10 workers, attach the information for only 10). 5. This information is about services performed by the worker from to. (Date) (Date) 6. State worker s occupation and title and give a complete description of the services provided: 7. How did the worker learn of the job (e.g., advertisement in newspapers, and word of mouth): 8. What were the requirements for the worker s position (e.g., previous experience, and education): 9. Is the worker still performing services for the firm? Yes No If No, explain why and how the worker was terminated: 10. Were the services performed under a written agreement or contract? Yes No If Yes, please attach a copy. 11. If the agreement was not in writing, or the terms of the written agreement were not complied with in practice, describe the actual terms and conditions of the arrangement: 12. Was it agreed or understood that the worker would perform the services personally? Yes No If No, please explain: DE 1870 Rev. 12 (2-09) (INTERNET) Page 2 of 7 CU

3 13a. Does the worker have helpers? Yes No If Yes, answer questions 13b. through 13g. If No, go to question 14. b. Were the helpers hired by: Worker The firm Unknown c. Who could discharge the helpers: Worker The firm Unknown d. Who paid the helpers: Worker The firm Unknown e. If the worker paid the helpers, did the firm reimburse the worker? f. What services do the helpers perform? g. Are social security (FICA), state disability insurance (SDI), and income taxes withheld from the helpers wages? If Yes, who reports and pays these taxes? 14a. Was the worker permitted to provide services for others during the same time periods services were performed for the firm? If Yes, answer questions 14b. through 14f. If No or Unknown, go to question 15. b. What percent of the worker s total working time was spent working for others? c. What percent of the worker s total income was earned from others? d. Describe services the worker performed for others: e. Did the firm have first call on the worker s time and efforts? f. Who owned or rented the premises where the services were performed? 15. List the kind and value of tools, equipment, and facilities furnished by the firm: 16. List the kind and value of tools, equipment, and facilities furnished by the worker? 17a. List any expenses connected with the services of the worker: b. Who was responsible for paying the expenses? c. Was the worker reimbursed by the firm for any of these expenses? Yes No 18. Did the worker perform under: His/her business name The firm s name 19. Did the worker advertise or maintain a business listing in the telephone directory, a trade journal, etc.? DE 1870 Rev. 12 (2-09) (INTERNET) Page 3 of 7 CU

4 20a. Did the worker hold himself/herself out to the public as available to provide services of this nature? b. Or any other nature? 21. Did the worker have an office or shop of his/her own? If Yes, where (e.g., was the office in the worker s home or was it rented office space?): 22a. Was a license or certificate required to perform the services? If Yes, does the firm possess such a valid license or certificate? Yes No b. Who issued the license or certificate to the firm and/or worker? State type and number for the firm and/or worker: c. Who paid the worker s license or certificate fee? 23. Did the firm engage the worker? Full-time Part-time Particular Job Indefinite Period Other, please explain: 24. Did the firm require the worker to perform during a scheduled time? Yes No 25a. Was the worker given training by the firm? Yes No If Yes, what kind and how often? b. Who paid for the worker s training expenses? 26. Was the worker required to follow daily, weekly, etc., routines or schedules established by the firm? Yes No If Yes, give examples: 27. Was the worker given instructions about the way the service was to be performed? Yes No If Yes, explain the nature of the instructions: 28. Could the firm change the methods used by the worker in performing the services or otherwise direct him/her as to how to perform the work? Yes No Explain your answer: DE 1870 Rev. 12 (2-09) (INTERNET) Page 4 of 7 CU

5 29a. Does the worker report to the firm or its representatives? Yes No If Yes, how often? b. For what purpose? c. In what manner (in person, in writing, by telephone, time record, etc.)? Attach copies of report forms used in reporting to the firm. 30. Was the worker required to produce a certain amount of work regularly if services were to continue? Yes No 31. Check the type of pay the applicant received? Salary Commission Hourly Other, please explain: 32. Was the worker guaranteed a minimum pay? Yes No 33. Was the worker eligible for a pension, bonuses, paid vacations, sick pay, etc.? Yes No If Yes, explain: 34. Did the firm carry workers compensation insurance on the worker? Yes No 35. Could the firm discharge the worker at any time? Yes No 36. Could the worker quit at any time? Yes No 37. Would a liability be incurred if the worker quit or was discharged before the job was complete? Yes No If "Yes," please explain: 38. Please explain why you think the worker is/was an employee of the firm or an independent contractor: 39. How did the worker report earnings for income tax purposes? Wages Self-employment Income Unknown ANSWER QUESTIONS 40 THROUGH 45 ONLY IF THE WORKER IS AN AGENT DRIVER OR COMMISSION DRIVER (AN AGENT-DRIVER OR COMMISSION DRIVER IS A PERSON WHO OPERATES HIS/HER OWN TRUCK OR THE TRUCK OF THE FIRM AND SERVES THE CUSTOMERS OF THE FIRM AS WELL AS SOLICITING HIS/HER OWN CUSTOMERS) 40. State the products and/or services the driver distributes (for example: bakery products and laundry services): 41. If the driver distributes more than one product or service, which is considered the principal or main product? Explain: 42. Does the driver serve? Customers or routes designated by the firm His/her own customers Both 43. Was the driver required to perform the services personally? Yes No 44. Were the driver s services part of a continuing relationship with the firm and not in the nature of a single transaction? Yes No 45. What investment, other than for transportation, does the driver have in the business? DE 1870 Rev. 12 (2-09) (INTERNET) Page 5 of 7 CU

6 ANSWER QUESTIONS 46 THROUGH 58 ONLY IF THE WORKER WAS A TRAVELING OR CITY SALESPERSON 46. What type of product is sold? 47. To whom are sales made? 48. What typical type of business is the buyer in? 49. Does the buyer resell the product or use it in its business? 50. Did the worker have an exclusive territory? Yes No 51. Did the firm specify when and how often to work the territory? Yes No 52. What percent of total sales that the worker made for the firm were made to wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar establishments? 53. What was the percent of working time that the worker spent in selling to organizations other than those specified in #52, such as manufacturers, schools, churches, and homeowners? 54. What was the approximate number of hours worked per day for the firm? 55. Was the worker required to perform the services personally? Yes No 56. Was the worker required to forward the orders to the firm? Yes No 57. Were the worker s services part of a continuing relationship with the firm? Yes No 58. What investment, other than transportation, does the worker have in the business? 0BANSWER QUESTIONS 59 THROUGH 67 ONLY IF THE INDIVIDUAL WORKED AT HOME 59. Who furnished materials or goods used by the worker? Individual Firm 60. Was the worker furnished a pattern or given instructions to follow in making the product? Yes No 61. Was the worker required to return the finished product either to the firm or to someone designated by the firm? Yes No 62. Was the worker required to perform the services personally? Yes No 63. Were the worker s services part of a continuing relationship with the firm? Yes No 64. Is the firm licensed by the California Division of Labor Standards Enforcement? 65. Does the worker have a valid permit from the California Division of Labor Standards Enforcement? 66. Who bears the cost of material damaged by the worker? Worker Firm 67. Explain the nature of any substantial investment in facilities used in connection with performance of the worker s services. DE 1870 Rev. 12 (2-09) (INTERNET) Page 6 of 7 CU

7 ANSWER QUESTIONS 68 THROUGH 72 ONLY IF THE INDIVIDUAL IS A REAL ESTATE SALESPERSON OR BROKER 68. Does the firm provide advances against unearned commissions, expense accounts, or reimbursements of expenses incurred by the worker? Yes No Please explain: 69. Does the firm approve the sales before they are placed in escrow? Yes No 70. Does the worker have any other duties with the firm besides selling real estate? Yes No If Yes, please explain the nature of such duties and the method of payment: 71. Does the firm allow the worker to have exclusive listings? Yes No 72. Does the worker have a valid license to sell real properties? Yes No ANSWER QUESTIONS 73 THROUGH 79 ONLY IF THE FIRM IS A TEMPORARY SERVICES EMPLOYER OR LEASING EMPLOYER 73. Does the firm negotiate with clients or customers for such matters as time, place, type of work, working conditions, quality, and price of the services? Yes No 74. Does the firm determine the assignments or reassignments of the workers, even though workers retain the right to refuse specific assignments? Yes No 75. Does the firm retain the authority to assign or reassign a worker to other clients or customers when a worker is determined unacceptable by a specific client or customer? Yes No 76. Does the firm assign or reassign the worker to perform services for a client or customer? Yes No 77. Does the firm set the rate of pay of the worker, whether or not through negotiation? Yes No 78. Does the firm pay the worker from its own account(s)? Yes No 79. Does the firm retain the right to hire and terminate workers? Yes No I declare that all copies of contracts and all statements submitted are true, correct, and complete to the best of my knowledge and belief. If any misrepresentation has been made or facts have been omitted, I understand that the determination will not be valid and will not be binding upon the Department. (NAME PRINTED) (SIGNATURE) (TITLE) (DATE) (PHONE NUMBER) DE 1870 Rev. 12 (2-09) (INTERNET) Page 7 of 7 CU

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